ADHD

Question 1

What problems are present with diagnosing ADHD?

Answer 1

1. Pressure from parents
2. Pressure from school
3. Time needed for thorough evaluation
4. Need to coordinate multiple resources to provide treatment
5. Time needed for follow-up and evaluation of effectiveness of treatment
6. Differential diagnosis

Question 2

What evidence supports the validity of ADHD?

Answer 2

1. Predictive validity
2. Cross-cultural Validity
3. Genetic studies
4. Imaging studies
5. Consistent impairments

Question 3

What is the current concept about ADHD?

Answer 3

1. Brain disorder of response inhibition in executive functioning (prefrontal)
2. Attention is different for different tasks (exciting stimuli may draw attention)

Question 4

What causes ADHD?

Answer 4

1. The causes of ADHD are multifactorial…with influences of environment, genetics and CNS influences
   A. Environment includes home, school and community
   B. CNS Injury/Insults—head trauma, hypoxia as neonate, etc

Question 5

How do symptoms of ADHD change as a pt gets older?

Answer 5

1. Inattention remains constant
2. Hyperactivity decreases
3. Impulsivity
4. 40% outgrow symptoms of ADHD, 60% continue to have some impairing symptoms into adulthood
   decrease

Question 6

What are potential areas of impairment for children with ADHD?

Answer 6

1. Academic limitations
2. Poor peer relationships
3. Increased injuries

Question 7

What are potential areas of impairment for adolescents with ADHD?

Answer 7

1. Low self-esteem

2. Risk-taking activities: smoking, substance abuse, sexual activity

Question 8

What are potential areas of impairment for adult with ADHD?

Answer 8

1. MVA
2. Legal difficulties
3. Occupational/vocational

Question 9

What are the types of ADHD?

Answer 9

1. Combined Type
2. Predominantly Inattentive Type
3. Predominately Hyperactive-Impulsive Type

Question 10

What are sxs of inattention?

Answer 10

1. Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities.
2. Often has trouble holding attention on tasks or play activities.
3. Often does not seem to listen when spoken to directly.
4. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., loses focus, side-tracked).
5. Often has trouble organizing tasks and activities.
6. Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or homework).
7. Often loses things necessary for tasks and activities (e.g. school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).
8. Is often easily distracted
9. Is often forgetful in daily activities

Question 11

What are the inattentiiveness criteria?

Answer 11

Six or more symptoms of inattention for children up to age 16, or five or more for adolescents 17 and older and adults

Question 12

What are the hyperactivity and impulsivity criteria?

Answer 12

Six or more symptoms of hyperactivity-impulsivity for children up to age 16, or five or more for adolescents 17 and older and adults

Question 13

What are the sxs of hyperactivity and impulsivity?

Answer 13

1. Often fidgets with or taps hands or feet, or squirms in seat.
2. Often leaves seat in situations when remaining seated is expected.
3. Often runs about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeling restless).
4. Often unable to play or take part in leisure activities quietly.
5. Is often “on the go” acting as if “driven by a motor”.
6. Often talks excessively.
7. Often blurts out an answer before a question has been completed.
8. Often has trouble waiting his/her turn.
9. Often interrupts or intrudes on others (e.g., butts into conversations or games)

Question 14

What is combined presentation?

Answer 14

if enough symptoms of both criteria inattention and hyperactivity-impulsivity were present for the past 6 months

Question 15

What is predominately inattentive presentation?

Answer 15

if enough symptoms of inattention, but not hyperactivity-impulsivity, were present for the past six months

Question 16

What is predominately hyperactive-impulsive presentation?

Answer 16

if enough symptoms of hyperactivity-impulsivity but not inattention were present for the past six months.

Question 17

What are the genetic factors for ADHD?

Answer 17

40% parents affected
35% siblings affected
Hypofunctional dopamine system in frontal lobes

Question 18

What external factors can contribute to ADHD?

Answer 18

Perinatal injury
Maternal drug/alcohol use
Toxins/Lead
Social-cultural factors
Family factors (disruptive family, absent parent, impaired parent, abuse)

Question 19

What dx studies can be used for ADHD?

Answer 19

1. Abnormal PET scans
2. Neurotransmitter imbalance
   A. Dopamine
   B. Serotonin
3. Not related to allergies, sugar, food additives

Question 20

What factors may be asst. with ADHD?

Answer 20

1. Mental Retardation
2. Learning Disabilities
3. 25-50% of L.D. have ADD
4. 10-30% of ADD have L.D.
5. Neurological Disorders
6. Enuresis/Encopresis

Question 21

What are the ddx for ADHD?

Answer 21

1. Mood Disorders
2. Anxiety Disorders
3. Psychosis
4. Pervasive Developmental Disorder
5. Learning Disabilities
6. Poor environmental controls
7. Family Dysfunction
8. PTSD
9. Oppositional Defiant Disorder
10. Conduct Disorder
11. Tourette’s Syndrome
12. Age – appropriate over-activity

Question 22

What factors can be used to help diagnose ADHD?

Answer 22

1. Family – parents (individually), siblings, extended family
2. School
   A. Teachers
   B. Report Cards
3. Past Medical Records
4. Rating Scales – Vanderbilt, BASC
5. Psychological Evaluations
6. Family History
7. Home Environment
8. Social Events
9. Babysitters
10. School Functioning
11. Peer Relationships
12. Police Records, problems with authority
13. Associated Complaints

Question 23

What domains does the Vanderbilt Rating Scale cover?

Answer 23

1. Inattention
2. Hyperactivity
3. Oppositional Defiant
4. Conduct
5. Anxiety/Depression
6. Performance

Question 24

Who can you refer ADHD pts to?

Answer 24

1. Psychological Testing
A. I.Q.
B. Learning Disabilities
2. Psychiatric Consult
3. Neurology Consult

Question 25

What is the pre-school ADHD presentation?

Answer 25

1. Very hyperactive: always, always on the go 2. Dangerously daring 3. Multiple accidental injuries 4. Very destructive play 5. Difficulty with the initiation of sleep is common 6. Low levels of compliance 7. Difficulty sustaining baby sitters or day care

Question 26

What are the assessment challenges for preschool children?

Answer 26

1. ADHD-like behaviors may be developmentally normal in this group when they are mild to moderate and without impairment 2. ADHD versus environmental versus developmental disorder versus ODD/BPD 3. Early intervention change trajectory?

Question 27

What are the treatment goals?

Answer 27

Improved Cognition Decreased motor activity Improved social skills Improved efficiency

Question 28

What factors can delay the diagnosis of ADHD?

Answer 28

1. Primary Inattentive Subtype 2. Female Sex 3. Highly Supportive Family 4. High IQ 5. Well Developed Social Skills

Question 29

What are the assessment challenges for adolescent children?

Answer 29

1. Multiple teachers for shorter periods of observation 2. Less observation time with the parents 3. Different clinical presentation of ADHD in adolescents 4. How do we assess clinical information and rating scales from the teen, parents and teachers? 5. Increased rate of co-morbid conditions in adolescents compared to elementary school-age children

Question 30

What is the treatment plan for ADHD?

Answer 30

``` 1. Multimodal Treatment Plan A. Behavioral Counseling B. Parenting Classes C. Medication D. School Involvement E. Activities F. Other Problems 2. Regular Follow-up and Re-evaluation ```

Question 31

What pyschoeducation may be helpful in treating ADHD?

Answer 31

Parenting Classes | Reading Materials

Question 32

What behavioral counseling may be helpful for pts with ADHD?

Answer 32

CONSISTENCY Positive Reinforcement Time Management Parents / Child / School

Question 33

What are the general principles for medical treatment?

Answer 33

1. Perform a thorough diagnostic and bio-psycho-social evaluation 2. Children & adolescents are embedded in family and neighborhood networks involving parents/caretakers, siblings, friends, schools, etc. 3. Psychiatric medications are generally just one part of a multimodal multidisciplinary treatment plan 4. Medications cannot replace need for therapeutic support, behavioral strategies, problem-solving, etc. 5. Children and adolescents developmentally different than adults: learn the differences by medication class for efficacy and side effects 6. Children may require proportionately higher doses: faster metabolism, greater kidney clearance, and greater liver-to-total-body-size ratio 7. Fully involve the family and child in the decision-making process about use of medications (shared decision making) A. Inquire about concerns, continue to address their concerns 8. Treat primary diagnosis (or the most urgent or impairing problem) with indicated medication first 9. Use systematic rating scale to measure symptoms at baseline and throughout treatment 10. Whenever possible, use medications supported by double-blind RCTs for this age group and diagnosis 11.Start low, go slow, taper slow (exception: stimulants can be discontinued more quickly) 12. Use medications at appropriate dose for adequate duration before changing or augmenting 13. Minimize use of multiple medications 14. When changing meds: Make only one med change at a time; monitor results A. Always consider environmental strategies as alternative or complement 15. Use systematic rating method to measure side effects 16. Evaluate iatrogenic effects of multiple medications A. When unclear, consider tapering or discontinuing most worrisome medication or the one with the least amount of RCT evidence

Question 34

What meds are stimulants?

Answer 34

1. Methylphenidate (eg: Ritalin, Concerta, Focalin) | 2. Amphetamine (eg: Dexedrine, Adderall, Vyvanse)

Question 35

What meds are non-stimulants?

Answer 35

1. Atomoxetine (Strattera) 2. Guanfacine XR (Intuniv) 3. Clonidine XR (Kapvay)

Question 36

What is the moa of MPH?

Answer 36

1. exerts much of its effect through dopamine uptake blockade by inhibition of dopamine transporter (DAT) of central adrenergic neurons 2. increase spontaneously released dopamine that enhances response to environmental stimuli

Question 37

What is the moa of amphetamines?

Answer 37

1. amphetamines not only block DAT, but also increase catecholamine release as a primary mechanism. 2. Increase spontaneously released dopamine that enhances response to environmental stimuli

Question 38

What is the moa of Atomoxetine (Strattera)?

Answer 38

Atomoxetine (Strattera) blocks reuptake at the noradrenergic neurons

Question 39

What is the moa of Guanfacine XR and Clonidine XR?

Answer 39

alpha-2A adrenergic receptor agonist

Question 40

What is the initial medical workup for stimulants?

Answer 40

1. Physical Exam 2/ Height and Weight 3. Blood Pressure and Pulse 4. Lab tests as baseline data (cbc and dif, LFT) 5. Screening for tics, involuntary movements 6. Pregnancy Tests 7. ECG if family hx of cardiac arrythmias

Question 41

What are the SE of stimulants?

Answer 41

``` Decreased appetite Insomnia Gastrointestinal pain Rebound phenomena Mood swings and irritability Increased heart rate (clinically insignificant) Growth retardation Tic disorders Psychosis Mood swings / depression Increased heart rate and BP (significant) ```

Question 42

What are the general considerations for prescribing and titrating?

Answer 42

1. Children < 5 yrs should not be given stimulants as a treatment of first choice 2. Probability of positive response less 3. Higher incidence of side effects 4. Few controlled research studies 5. Risk of drug abuse is greater in adolescents. Obtain detailed history. 6. Patients failure to respond to one stimulant does not preclude a positive response to another stimulant 7. Although body weight has not shown to be related to drug response, it may be used as a rough guideline for determining starting dose. 8. Giving the dose after meals decreases side effects on anorexia and stomachaches

Question 43

What are the outcomes for ADHD?

Answer 43

1. 25% - symptoms abate 2. 75% - symptoms persist, usually less hyperactivity 3. Increased risk for Conduct Disorder and Antisocial Personality Disorder 4. Increased risk for psychiatric problems 5. Adult ADHD 6. Ritalin abuse

Question 44

What are the dopamine pathway functions?

Answer 44

1. Reward/motivation 2. Motor function fine tuning 3. pleasure 4. compulsion 5. perseveration

Question 45

What are the serotonin pathway functions?

Answer 45

1. Mood 2. Sleep 3. cognition 4. Memory processing

Question 46

How is the brain affected in ADHD?

Answer 46

1. ADHD is a developmental delay 2. Smaller, less active, less developed brain regions 3. Differences found more on the right side of the brain 4. Size of networks in brain correlated to the severity of ADHD presentation 5. Same ares of brain impacted by ADHD are those that are asst. with emotions, self awareness, and self regulation